“Learn it in one, derive it in two, put it in networks, change what you do” – Steven Hayes summarizing 30 years of his work related to Relational Frame Theory.

***Please note new content was added at end of post as of 4/15/2020

Inherently, Relational Frame Theory (RFT) is an extremely complex theory to explain in a short form. Hayes himself struggles with it and even the best written introduction to RFT from Niklas Törneke has proven difficult to consolidate in a single post. At its most basic level, RFT is the most empirically studied theory of human language and cognition. While it may be overwhelming at first, I encourage reading my previous post here, to learn about contextualism prior to, or after you read this post. Furthermore, I encourage readers to learn the importance of RFT being built on a functional contextualistic perspective, the basis of ACT and other therapies, and that this is fundamentally different than descriptive contextualism, the basis of narrative medicine (please read more here). Törneke does an impressive job of condensing this into 237 pages that are quite easy to read, even for someone who does not have a formal background in behavioral psychology. I would encourage ANY healthcare provider to purchase and read Learning RFT, as all of us are fumbling through our language, all of us have to speak, all of us have to educate, and all of us have to work with behavior. However, I believe there is far more to RFT than language and cognition, and there are notable implications for those of us in movement and rehabilitation as well. In an effort to limit how large this post gets I have consolidated my objective to asking two questions:

Why is RFT so important for those of us who work with pain?

Why may RFT be important to understand movement, in particular motor behavior?

Why is RFT so important for those of us who work with pain?

As previously discussed in the Coherence post series [Here], many of us in the movement and rehabilitation field have come to realize that we are ultimately working in the field of behavior change. However, our efforts are haphazard, we lack solid ground for which to stand on, dabbling in cognitive behavior (CBT) strategies and conceptual change strategies, motivational interviewing, and others in combination with a curriculum of Therapeutic Neuroscience Education and Biopsychosocial concepts. All of these concepts involve engaging in language and cognition. These strategies assume that the “cognitive” part of humans is somehow open for change, “bad thoughts” can be challenged or deleted, and certain content can be swapped for other information. Unfortunately, by experience, it is quickly learned that any effort to “change clients minds” about deeply held beliefs is far more challenging than it would seem. Surely a more scientific explanation will change their mind, maybe they just need the right piece of knowledge, or if we argue with them on logic, logic will win out, right? By now you know this is not possible. It turns out that researchers who work primarily with cognitive behavior therapies have also started to realize that emphasis on changing thinking and the content of the mind do not appear to explain why cognitive behavior therapies work, nor are they necessary for behavior change to occur (See here).

What does this mean? It turns out we have very little control over our thoughts, our mind is constantly generating new thought and creating relationships between new and old thoughts. We might have a thought questioned, reframed, or challenged, but eventually the mind will use old relationships and networks to return to what it believes most supports the known content of self. This is exceedingly beneficial from a survival perspective as it means our brains are expert troubleshooters, always trying to create new connections based on old and new information in an attempt to keep us alive. While beneficial, this is also problematic. In particular during times in which no immediate danger is present, this troubleshooter does not stop generating thoughts, making new relationships, or building and connecting larger networks. As Törneke describes it, this is the dark side of human language, and worse yet, social factors both support and promote the rigidity of these relationships and networks. Think of our nocebic language in culture, “I have a bad back because my mom’s got a bad back,” “sit up straight or you’ll hurt your back,” “pain is bad, you should be pain free all the time,” “My pain will get worse as I get older, my spine will crumble,” these are reinforced through self and society. Our best efforts to address this by providing updated evidence rooted in science as “education” are quickly squashed the moment their mind starts to sort through its existing networks yearning for coherence after they leave our space, or even more challenging, speak with a 3rd party human who does not share this new knowledge. Upon presenting the new “knowledge” to the 3rd party human, now that 3rd party human’s beliefs are also questioned with the new knowledge introduced to 1st party human (our client) which activates their efforts to maintain a coherent story in their mind (and the broadly accepted societal narrative) and not wanting to have a disconnect with the friend human’s new knowledge, 3rd party human immediately challenges 1st party human in an effort to defend the coherence of the content in their mind, and in the end old networks are reinforced for both humans that the content in their mind reassures them that in fact, they still broken and hopeless. However, what RFT shows us is that we don’t even need other people to mess with the new knowledge. To give an example I took from Hayes that I like to use in my courses and with clients:

If I wanted to stop eating donuts as a method of losing weight and I thought to myself, I’m going to associate donuts with dirty hats! That’ll work, except, as we’ve learned through the development of RFT, that relationship immediately derives itself two ways. So now lets say I see a donut and I think of hats, what they look, smell and taste like. Awesome, success right? Except now, the next time I see a hat, what do I think of?… Crap, donuts… mmmmm.

Research on RFT has seen the same with positive thoughts: at the tail end of every positive thought and everything positive line of thinking you make in your life, is also the negative thought you were avoiding. Efforts to suppress or “delete” negative thoughts results in worsening negative thoughts and feelings. The human mind does not have a delete button. You can’t get rid of the other end of the spectrum. It will always be there. In my own experience as a patient, having seen my own MRIs, X-rays, and reports, I cannot delete those images and thoughts from my mind, no matter how much I have read and understand the evidence that those spinal changes are normal. I will never be able to “un-see” them, and I still hold relationships of those images with fear, uncertainty, and pain. This means for the rest of my life, I will still have to work with those thoughts and memories and the numerous contexts in which they will arise. These are now parts of my “self-as-process” and “self-as-story” which are parts of a very important area in which RFT has shed light: the experience of self.

Self

In RFT, the experience of self is divided into an umbrella of two parts, self-as-perspective (observing mind, transcendent mind, among many other names) and “content of self”. The content of self is further divided into self-as-process and self-as-story. Self-as-process is the “ongoing, observable process of ourselves”, such as memories, emotions, bodily sensations, and thoughts. It only exists here and now and as a result, is open for change. This dynamic nature of self-as-process is important because this means memories are not always thought of or remembered in the same way, nor does sensation always feel the same, and our emotional state and how we interpret emotions is also variable. Self-as-story is the “who I am”, identity part built on our history, and it is important that this story is coherent and a connected whole. The self-as-perspective, or observing self, is difficult to describe. As Hayes describes it, “it’s borders are fuzzy”, we cannot observe it and it is devoid of content, it is the lens through which we look that is not influenced by what it sees. The observing self is also a powerful process to engage in from a therapeutic perspective, classically emphasized in mindfulness strategies but explicitly engaged with Acceptance and Commitment Therapy. While there are numerous directions (in particular “I/you”, “here/there”, “now/then” relationships!) for which I could take this and future posts, I will for now leave these for specific courses on these approaches and end on the note that the experience of self, as defined by RFT, provides a clinical framework for understanding the difficulty of addressing beliefs, memories, relationships with emotions and sensations, and sustainable behavior change. As professionals who help clients who struggle with pain, we owe it to ourselves to better understand these layers and respect the challenges of engaging in human language and thought processes.

Why may RFT be important to understand movement, in particular motor behavior?

With this question I am moving beyond much of what RFT was developed for and studied. Despite the initial intentions of RFT, what it has done with expanding on Skinners work with operant conditioning and verbal behavior, also has profound implications for movement. Examining motor control and movement from a behavior perspective is clearly not new (see here, here, here, here for some introduction) but what seems to be forgotten is that it behavior in context is the fundamental underpinning of movement. However, it seems that popular beliefs and traditions of movement have fallen back into the idea of fixed motor patterns and programs despite an abundance of evidence that these ideas miss the basic principles of motor control. I suspect it’s the overwhelming nature of the idea of context and what behavior means to so many rehabilitation professionals, and they do not know what to do with that information clinically.

In this vein, I believe RFT is a way forward to help movement and rehabilitation professionals understand that they are always observing behavior in context. Understanding the worldview lenses for which we could perform research or create practical (pragmatic) applications allows us to confident in the coherency of what we are doing. Specifically transitioning from a mechanistic or organicism viewpoint to a functional contextualistic viewpoint which underpins RFT means we can practically work with complexity, rather than being overwhelmed with the mechanistic nuances. Understanding relationships can be formed between a sensory (in particular to us, sensorimotor), cognitive, or emotional experience (which serve as stimuli), and these relationships can be derived to form into networks, and how these networks interact change the way we move, provides a practical way to assess and interact with movement behavior. This substantially expands and improves on, or perhaps corrects, what I previously called “Post-Antalgic Patterning.” Through the RFT lens, these patterns are simply behaviors and do not necessarily even imply “guarding” or “protecting”, they are simply motor behaviors built on relationships and networks. Using the example of an acute ankle sprain, given the sensory stimuli from the acute injury, a relationship may be formed with the respective nocifensive behavior that results in a limp. Any part of the motor behavior that manifests as a limp could be related with any stimuli, and the resulting networks could also be associated with other movement networks. Furthermore, that ankle sprain occurred in a human, therefore it did not occur without thoughts or emotions. Were catastrophic thoughts related to the degree of tissue injury present? What is the history of those thoughts, have they been associated with other networks that include movement behavior pairing? What implications do those thoughts have with future behavior? Could new movement behavior develop in the absence of a paired non-motor stimuli simply by establishing relationships between movement behaviors? Could emotions such as fear, anger, or uncertainty be paired with these movement behaviors and could they also coordinate with other networks? As relationships grow in two way relationships, so do network relationships.

The bottom line is the opportunity for old and new relationships to present now or in the future is limitless, and our current exercise prescriptive models do not account for these infinite relationships. We do not know, nor can we 100% predict what it is about an exercise that results in the behavior change we feel is necessary for progress. There are generalizations, but as a whole, we’re taking part in a process. The widely accepted mechanistic viewpoint in our movement and rehabilitation tradition cannot support the contextual nature of movement behavior, and we would propose shifting to a functional contextualist perspective to practically work with movement in a meaningful way. This requires a shift to a process-based framework and approach for movement and pain, and we would like to provide a suggestion for such a framework in the next post.

Visualization of RFT related to Movement & Pain – Added 4/15/2020

Below is a gross visualization of the near infinite number of relationships between various forms of stimuli and behaviors that could be attached to a simple acute ankle sprain: